The next few weeks are going to be bad, folks. Here’s what experts from Stanford on the front-lines predict: peak COVID-19 cases will not be until July 2020, with a total number of deaths in the USA ranging from 500,000 to 1 million. That’s sobering.

If we had instituted a nationwide lockdown last week, we may have seen infections die down over the next 2 months, as happened in Hubei province and across China. Similarly, Singapore, South Korea, and Hong Kong brought their cases to manageable levels through social isolation and mass testing in the 100s of thousands of people. Many of them even before they had symptoms. Singapore sent every citizen masks and every carrier was followed by five people. 

The three main tests are: 

1. Test for the viral RNA (so-called PCR tests) 
2. A 15-minute antibody test for the SARS-CoV-2 spike protein which is less reliable (89% sensitive).
3. The third type of test is “DNA sequencing” which will be important to track the evolution of the virus and detect co-infections that make the condition worse, like flu, colds, and bacteria called pneumococci that cause bacterial pneumonia.

But the US, Europe, and Australia are not like China, and certainly not Singapore. Most leaders are currently reluctant to issue draconian blanket orders. They worry about the effect on small businesses. They worry many people don’t have health insurance. They worry about the dwindling cash reserves of companies and individuals. 

What should we expect from here? 

At first, I was worried about reinfection. Rumors out of China said this might be possible. New studies in monkeys suggest this is extremely unlikely. That’s very good news for humanity. But there will be a lot of pain for the rest of the year. There may be a repurposing of hotels to be intensive care units (ICUs) in the coming weeks. The governor of California says don’t expect kids to go back to school this year. Hospitals are starting to look like a scene from M*A*S*H, with tents outside and long lines of people waiting for testing. No visitors allowed. All non-essential operations are postponed. There are very few infectious disease doctors at each hospital, sleeping from midnight to 4 AM, walking around wards in what look like spacesuits. ICUs are already in chaos in major cities. And this is an early stage. What happens a few weeks from now?

This is why scenes from Florida of youths continuing to party and congregate are extremely worrying. Many of them will unwittingly carry the virus back to their friends and families. Unless there’s a lockdown of all of us for two months at least, except for essential staff, the viral spread will continue at high rates and will continue to overwhelm hospitals. Beds, ventilators, and nurses will be in short supply. Hospital staff will contract COVID-19. Already, the number of nurses has been on the decline for years. When hospitals run out of ventilator machines, then, like Italy, doctors will have to make heart-wrenching decisions who to help and who to let die. While this may not sound that bad, imagine it’s your parent or grandparent who is denied the ventilator. 

As I write this, my friend Dr. Peter Attia just received word from an ICU doctor at a small NY hospital that they are officially out of ventilators and are doubling up ventilators to keep 2 patients alive with one machine.

I am often asked, “How do I know I’m infected?”  Based on formal accounts out of China and Australia, in the first few days of infection you probably won’t know you have it. You will be leaving a trail of viral particles at home, on food, on elevator buttons, or at the grocery store or restaurant. Droplets, skin contact, surfaces, and food seem to be how it’s transmitted. 

Fomites (surfaces that spread disease) can infect you 24-96 hours after someone has contaminated it, depending on whether it is steel or plastic. Droplets from breath can stay in the air for 30 minutes before falling to the ground. If you can smell someone’s breath, say if they had recently smoked or ate garlic, you can be infected. Think of these droplets like they were a fog.

Coronaviruses usually cause mild to moderate upper-respiratory tract illnesses, like the common cold. However, three times in this century coronavirus outbreaks have emerged from animal reservoirs to cause severe disease and global transmission concerns, SARS (2002-4), MERS (2012 and remains in camels) and COVID-19 (2019, with the greatest similarity to bat coronaviruses). Why they are emerging now and not last century is not clear but theories include climate change and greater human-wild animal contact, as more humans push further into virgin forests and use “bush meat” for food.

Coronavirus disease 2019 (COVID-19) usually begins like you are getting a cold. You will have a dry, raspy throat. Maybe a headache. You may have a dry (but not wet) cough. You almost certainly won’t be sneezing (that’s the common cold). Within days, you’ll feel like you’ve got the flu, with a high fever, aches and pains. Sometimes you can feel like you are recovering - until the pneumonia starts. 

That’s when your lungs can’t get enough oxygen and you develop crepitance, when your lungs crackle because there’s not enough surfactant (biological detergents). Think of a balloon that’s wet on the inside. Because the virus also attacks the heart, pericarditis can also occur in the late stages, leading to cardiogenic shock and death due to cardiac arrest. Other organs that get attacked are the kidney and gut. Even the lining of blood vessels.

As of today, March 18th, more than 8000 people globally have died. There are more than 200,000 confirmed cases in at least 146 countries/territories, according to the World Health Organization. 

Fatality rates vacillate between 0.7% and 6% depending on the number of tests that are taken and the number of critical care units still available in the region. The R0, the number of people a carrier infects, is between 2 to 4. That means that for every 1 person that contracts the virus, 2 to 4 will become infected. 

In the US, we expect a doubling of cases every six days. That means we are looking at about 1 million cases by the end of April.

Then 2 million by May 7.

Then 4 million by May 13.
 

We are no longer able to wipe this virus off the face of the planet by containment, so currently, the strategy is two-fold — flatten and delay:

1. We need to flatten the curve rate of infection to help ease the pressure on our healthcare system. We need young people especially to help us fight this by staying inside and self quarantining. 

2. Somewhere between 33% and 75% of us will catch this disease, unless we can delay it until a vaccine trial is successful, which is another 18 months away, assuming it does work. I am hopeful but, until then, we have to live with corona. 

Ultimately, we will get to what’s called a “herd immunity”. That means that enough of us have developed a resistance to COVID-19 that the R0 is less than one. When that happens, the virus should eventually peter out. 

What seems to work is chloroquine, also known as Planiquil, a malarial drug doctors in China showed in small trials did help (though this is now apparently questioned by doctors in the USA). 

There’s a 50% chance remdevisir, an investigational broad-spectrum antiviral treatment from Giliead Pharmaceuticals, which seemed to limit MERS symptoms in animal tests, will also help COVID-19 patients. Trials began on Feb 25th at the University of Nebraska, Omaha, sponsored by the National Institutes of Health. Results will likely be known in a few months. In the meantime, doctors are prescribing remdevisir off-label.

Treatments that doctors say don’t work are colloidal silver, ganciclovir and related antivirals, anti-inflammatory steroids such as prednisolone, and there’s new caution out of France being placed on ibuprofen, which is said to make symptoms worse. Acetaminophen, which is not an anti-inflammatory, seems fine to use at home, but not in large amounts and never should be taken with alcohol. 

Tamiflu seems to suppress the virus' reproduction in at least some cases which are somewhat surprising as Tamiflu was designed to target an enzyme on the influenza virus, not on coronaviruses. A test vaccine for the first SARS virus that targeted the corona spike protein actually backfired and made infected monkeys worse, so doctors have to be careful when testing new COVID-19 vaccines on humans, especially because most target the spike protein.

Other drugs under investigation include Kaletra, Aluvia, Prezcobix, Truvada, PegIntron, Sylatron, Xofluza, Kevzara, Galidesivir, Ganovo, Bevacizumab, recombinant ACE2, PD-1-blocking antibody, thymosin, placenta-based cell therapy, and a CCR5 antagonist, along with more than 40 vaccine trials globally.

Humanity is fighting back!